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	We can quote on your plan. Please complete the information in this form, and we will get back to you with a quotation on a plan for your business. If you have more employees than our form can accommodate, please use our contact form to get in touch with us and we will contact you directly. Company Name*   State*   Zip*   Contact Name & Title*   Phone*   Best Time to Call*   Fax   Email*   Do You Have Benefits Now?   No Yes (if Yes, please answer next 5 questions) Who Is The Insurer:   Average Monthly Premium:   /Employee Type Of Plan   Not Sure PPO HMO POS Renewal Month   Jan Feb Mar Apr May Jun JulAug Sep OctNov Dec What Was Increase Last Year?  % Will This Plan Be Voluntary?   No Yes   Please list all employees working at least 20 hrs per week and 10 months per year
Employee Name Or Number Date of Birth (MM/DD/YY) or age Cover Your Spouse? Number of Children Are You a Smoker 1 No Yes 0 1 2 3+ No Yes 2 No Yes 0 1 2 3+ No Yes 3 No Yes 0 1 2 3+ No Yes 4 No Yes 0 1 2 3+ No Yes 5 No Yes 0 1 2 3+ No Yes 6 No Yes 0 1 2 3+ No Yes 7 No Yes 0 1 2 3+ No Yes 8 No Yes 0 1 2 3+ No Yes 9 No Yes 0 1 2 3+ No Yes 10 No Yes 0 1 2 3+ No Yes 11 No Yes 0 1 2 3+ No Yes 12 No Yes 0 1 2 3+ No Yes 13 No Yes 0 1 2 3+ No Yes 14 No Yes 0 1 2 3+ No Yes 15 No Yes 0 1 2 3+ No Yes

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